AQ_F_2000123_20221212_EI_PreForm

List of Contents of this Inventory Package
The list below is a summary of the forms contained in this package.
1. Pre-Submittal Check List(optional tool for your use and benefit as a double check before submittal).
2. Listing of Emission Sources and Control Devices on Permit List(check list to use for organization,review and keeping
track of data previously submitted and in the inventory)
3. Blank Emission Source/Operating Scenario Data Form-make multiple copies to be used to fill in individual Operating
Scenario information
4. Facility Total Emissions Summary Form To use to summarize facility-wide emissions, summed from individual Emission
Source/Operating Scenario Data Forms, for each pollutant.
5. Certification Form for use and signature of Responsible Official must be mailed(postmarked)by inventory due date.
1

NC DEQ, Division of Air Quality
Emission Inventory Pre-Submittal Check List
The following list provides some suggestions for you to use in reviewing your Air Emission Inventory submittal.It is meant
as a reminder of some of the key points to be remembered.It is not meant to be all inclusive or to repeat many important
parts of the instructions.Persons who have questions are reminded to contact their Division of Air Quality regional office.
Verify Action to Check(X)
Has the "Responsible Official'reviewed the information submitted and certified it as correct by means of a
signature in blue ink on the correct Certification Form?
Is your postage sufficient and have you arranged for"return receipt requested?"
Have you included emission estimates for all emission sources/operating scenarios and all pollutants,using the
"best available information?"
Is each form and each supplemental page clearly marked with your Facility ID,Permit Number and other
identification sufficient for each page to be properly replaced in your package if it should become separated?
Did you include emissions for all HAPs and TAPS separately, even if they may be part of VOC or PM-10 totals,
realizing for Title V billing purposes they will NOT be double counted/billed?
Have you shown proper"affiliations"between each emission release point and operating scenario within the
facility?
Are all forms completely filled out and in correct order?
Have you adequately researched and documented the best information to use to estimate your emissions?Have
you considered testing or supporting your industry association in testing programs to develop better emission
factors?
Have you used the proper address so that the submittal goes to the proper DAQ regional office for the county in
which the facility operates?
Did you evaluate whether a General Facility Information Form is required?
Did you provide the certified original of forms with calculation documentation and one additional copy of forms?
Submit packet of completed forms to the appropriate Regional Office as specified in your cover letter.Do NOT send them to
DAQ Central Office.Do NOT Fax.
This check list is provided for your convenience.You are not required to use it or send it to the Division of Air Quality.
Your Division of Air Quality contact is
Michael Koerschner
Asheville Regional Office
2090 U.S.Highway 70
Swannanoa NC 28778
828-296-4500
2

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Listing of Emission Sources and Control Devices on Permit. See instructions
ES ID on ES Description CS Description CD ID's on Permit
Air Permit
one natural gas/No.2(virgin or recycled)
fuel oil\No.4(virgin or recycled)fuel
oil-fired hot mix asphalt batch plant(88
million Btu per hour maximum heat one knock-out box(1,408 cubic feet)(CD2)in series with
ES1 input rate while combusting natural gas one bagfilter(11,084 square feet of filter area)(CD I) CD2,CD
and 110 million Btu per hour maximum
heat input rate while combusting fuel
oils)processing asphalt and reclaimed
asphalt product(RAP)
ES2 one hot mix asphalt storage silo(200
tons storage capacity)
ES3 one main plant truck loadout operation
ES6 one hot mix asphalt storage silo truck
loadout operation
ES7 hot mix asphalt storage silo(200 tons
storage capacity)
ES8 hot mix asphalt storage silo(200 tons
storage capacity)
One No.2 fuel oil-fired asphalt tank
I-1 heater(1.38 million Btu per hour heat
input)
1-2 fuel oil storage tank(10,000 gallon
capacity or less)
*If blank, no data recorded in DAQ System.
*CD = Control Device.
*CS =Control System.
*ES =Emission Source.
3

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source & Operating Scenario List- See Instructions
*ES Group ID *ES ID *OS ID �OS Description Forms Did Not Operate Not Required to
Completed Report
ES2,ES1,
GRl ES3,ES6, 1 hot mix asphalt production
I-1
I-2 NONE NONE
ES7 NONE NONE
ES8 NONE NONE
*Blank, if not part of a group.
*ES =Emission Source
*OS = Operating Scenario
Form Completed=Form printed and completed.
Please return this completed Form with your submittal. Be sure to fill in with 'X' or similar mark if the ES or OS did
not operate and/or if it was Not required to report.
4

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source/Operating Scenario Data
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
1.Emission Source ID (from permit) Group GR1 Consisting of ES2, ES1, ES3, ES6, I-1
or Emission Source Group ID
2. Emission Source Description : asphalt plant(drum dryer,heater,silo,truck loadout)
3. Operating Scenario ID/ OS - 1/hot mix asphalt production
Description:
4. SCC Number/Description: 30500252 /Asphalt Concrete -Dryers ; Conventional Batch Mix Plant:
Rotary Dryer, Oil - Fired
5. Throughput/units in 2022: / TON/yr
(e.g.production or fuel use):
6. Fuel Information %Sulfur %Ash Heat Content
(If fuel is used) /
(Btu/units)
7. Capture Efficiency
(%of Emissions from this Process Vented 100
to Control Device or Stack):
8. Control Device Information
Order CS-ID CD ID Control Device Description
(as listed in permit)
1 CS-1 CD2 one knock-out box (1,408 cubic feet)
2 CS-1 CD 1 one bagfilter(11,130 square feet of filter area)
9. Emission Release Point(ERP)Information: (Sources vented to more than one ERP use additional entry lines):
ERP ID ERP Type Height Diameter Temperature Velocity Volume Flow ERP Description
(in feet) Circle(enter#): (Feet/sec)
Rectangle(L x R) (F) Rate
(in 0.1 feet) (Aefm)
ERP-1 VERTICAL 28 4 225 64.27 48458.43 drum dryer stack
STACK
10. Operating Schedule:(Source/OperatingScenario that best characterizes Calendar Year 2022)
Hours per Day ( ) Days per Week ( ) Weeks per Year ( )
11. Typical Start& End Times For Operating Scenario: Start: End:
12. Seasonal Periods Percent Annual Throughput:
Jan-Feb + Dec I % March-May % June-Aug. 0Sept.-Nov.
2022 2022 2022 2022
5

Operating Scenario: OS - 1 Emission Source/Group ID: GR1
13. Actual Emissions per Pollutant Listed
Attach calculations and documentation of emission factors or other estimation methods used.
Emissions Emission Control
GHG CAS Estimation
Pollutants (see instructions) GHG Pollutants Mthd Cd Efficiency
eo oe
(Tons/Year) (Net after all controls)
(See Instructions)
2022 2014
Emissions- Emission Control
Criteria Pollutant Estimation
(NAAQS) Pollutants Code Criteria Pollutants Method Code Efficiency
(Tons/Year) (Net after all controls)
(See Instructions)
2022 2014
CO CO
NOx NOx
TSP TSP
PM10 PM10
PM2.5 PM2.5
S02 S02
VOC VOC
Emissions Emission Control
HAP/TAP/Other Pollutants (In CAS Estimation
Alphabetical Order) (see instructions) HAP/TAP/Other Mthd Cd Efficiency
eo oe
(Pounds/Year) (Net after all controls)
(See Instructions)
2022 2014
6

Operating Scenario: OS - 1 Emission Source/Group ID: GR1
Comments regarding this Operating Scenario (identify by field orgeneral):
If you do not provide all information your inventory will be deemed incomplete and returned to you
To review detailed instructions or other information, go to web page: https://deg.ne.gov/about/divisions/air-quality/air-quality-
data/emissions-inventories/emission-inventories-tools
Most information on this form is not subject to claims as confidential business information.
The emission inventory must be returned(Postmarked) to the appropriate DAQ regional office by May 02,2023.
If pre-filled information is incorrect,please strike over and replace with correct information.
7

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source/Operating Scenario Data(Data here resulted from information entered into the system earlier by you or DAQ staff)
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
1.Emission Source ID (from permit) I-2
or Emission Source Group ID
2. Emission Source Description: fuel oil storage tank(10,000 gallon capacity or less)
3. Operating Scenario ID/
Description:
4. SCC Description:
5. Throughput/units in 2022: /
(e.g.production or fuel use):
6. Fuel Information %Sulfur %Ash Heat Content
(If fuel is used) /
(Btu/units)
7. Capture Efficiency
(%of Emissions from this Process Vented
to Control Device or Stack):
8. Control Device Information
Order CS-ID Control Devices ID Control Device Description
(as listed in permit)
9. Emission Release Point(ERP) Information:(Sources vented to more than one EPP use additional entry lines):
ERP ID ERP Type Height Diameter Temperature Velocity Volume Flow ERP Description
(in feet) Circle(enter ft (F) (Feet/sec) Rate (Acfm
Rectangle(L x W) )
(in 0.1 feet)
10. Operating Schedule:(Source/Operating Scenario that best characterizes Calendar Year 2022)
Hours per Day ( ) Days per Week ( ) Weeks per Year ( )
11. Typical Start & End Times For Operating Scenario: Start: End:
12. Seasonal Periods Percent Annual Throughput:
Jan-Feb +Dec I % March-May I % June-Aug. I % Sept.-Nov.
8

13. Actual Emissions per Pollutant Listed for :
Attach calculations and documentation of emission factors or other estimation methods used.
Emissions Emission
GHG CAS Estimation Control
Pollutants ( ) GHG Pollutants Efficiency Net after
see instructions
(Tons/Year) for year 2022 Method Code all controls)
(See Instructions)
Emissions- Emission Control
Criteria Pollutant Estimation
Criteria Pollutants Efficiency
(NAAQS) Pollutants Code ( ) y Method Code
TOriS/yeaY for year 2022 (Net after all controls)
(See Instructions)
CO CO
NOx NOx
PM(TSP) PM(TSP)
PM10 PM10
PM2.5 PM2.5
SO2 SO2
VOC VOC
Emissions Emission Control
HAP/TAP/Other Pollutants CAS HAP/TAP/Other Estimation
(In alphabetical order) (see instructions) Method Code Efficiency (Net aver
(Pounds/Year) for year 2022 all controls)
(See Instructions)
9

Comments regarding this Operating Scenario (identify by field orgeneral):
If you do not provide all information your inventory will be deemed incomplete and returned to you
To review detailed instructions or other information, go to web page: https://deg.ne.gov/about/divisions/air-quality/air-quality-
data/emissions-inventories/emission-inventories-tools
Most information on this form is not subject to claims as confidential business information.
The emission inventory must be returned (Postmarked) to the appropriate DAQ regional office by May 02, 2023.
If pre-filled information is incorrect,please strike over and replace with correct information.
10

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source/Operating Scenario Data(Data here resulted from information entered into the system earlier by you or DAQ staff)
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
1.Emission Source ID (from permit) ES7
or Emission Source Group ID
2. Emission Source Description: hot mix asphalt storage silo (200 tons storage capacity)
3. Operating Scenario ID/
Description:
4. SCC Description:
5. Throughput/units in 2022: /
(e.g.production or fuel use):
6. Fuel Information %Sulfur %Ash Heat Content
(If fuel is used) /
(Btu/units)
7. Capture Efficiency
(%of Emissions from this Process Vented
to Control Device or Stack):
8. Control Device Information
Order CS-ID Control Devices ID Control Device Description
(as listed in permit)
9. Emission Release Point(ERP) Information:(Sources vented to more than one EPP use additional entry lines):
ERP ID ERP Type Height Diameter Temperature Velocity Volume Flow ERP Description
(in feet) Circle(enter ft (F) (Feet/sec) Rate (Acfm
Rectangle(L x W) )
(in 0.1 feet)
10. Operating Schedule:(Source/Operating Scenario that best characterizes Calendar Year 2022)
Hours per Day ( ) Days per Week ( ) Weeks per Year ( )
11. Typical Start & End Times For Operating Scenario: Start: End:
12. Seasonal Periods Percent Annual Throughput:
Jan-Feb +Dec I % March-May I % June-Aug. I % Sept.-Nov.
11

13. Actual Emissions per Pollutant Listed for :
Attach calculations and documentation of emission factors or other estimation methods used.
Emissions Emission
GHG CAS Estimation Control
Pollutants ( ) GHG Pollutants Efficiency Net after
see instructions
(Tons/Year) for year 2022 Method Code all controls)
(See Instructions)
Emissions- Emission Control
Criteria Pollutant Estimation
Criteria Pollutants Efficiency
(NAAQS) Pollutants Code ( ) y Method Code
TOriS/yeaY for year 2022 (Net after all controls)
(See Instructions)
CO CO
NOx NOx
PM(TSP) PM(TSP)
PM10 PM10
PM2.5 PM2.5
SO2 SO2
VOC VOC
Emissions Emission Control
HAP/TAP/Other Pollutants CAS HAP/TAP/Other Estimation
(In alphabetical order) (see instructions) Method Code Efficiency (Net aver
(Pounds/Year) for year 2022 all controls)
(See Instructions)
12

Comments regarding this Operating Scenario (identify by field orgeneral):
If you do not provide all information your inventory will be deemed incomplete and returned to you
To review detailed instructions or other information, go to web page: https://deg.ne.gov/about/divisions/air-quality/air-quality-
data/emissions-inventories/emission-inventories-tools
Most information on this form is not subject to claims as confidential business information.
The emission inventory must be returned (Postmarked) to the appropriate DAQ regional office by May 02, 2023.
If pre-filled information is incorrect,please strike over and replace with correct information.
13

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source/Operating Scenario Data(Data here resulted from information entered into the system earlier by you or DAQ staff)
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
1.Emission Source ID (from permit) ES8
or Emission Source Group ID
2. Emission Source Description: hot mix asphalt storage silo (200 tons storage capacity)
3. Operating Scenario ID/
Description:
4. SCC Description:
5. Throughput/units in 2022: /
(e.g.production or fuel use):
6. Fuel Information %Sulfur %Ash Heat Content
(If fuel is used) /
(Btu/units)
7. Capture Efficiency
(%of Emissions from this Process Vented
to Control Device or Stack):
8. Control Device Information
Order CS-ID Control Devices ID Control Device Description
(as listed in permit)
9. Emission Release Point(ERP) Information:(Sources vented to more than one EPP use additional entry lines):
ERP ID ERP Type Height Diameter Temperature Velocity Volume Flow ERP Description
(in feet) Circle(enter ft (F) (Feet/sec) Rate (Acfm
Rectangle(L x W) )
(in 0.1 feet)
10. Operating Schedule:(Source/Operating Scenario that best characterizes Calendar Year 2022)
Hours per Day ( ) Days per Week ( ) Weeks per Year ( )
11. Typical Start & End Times For Operating Scenario: Start: End:
12. Seasonal Periods Percent Annual Throughput:
Jan-Feb +Dec I % March-May I % June-Aug. I % Sept.-Nov.
14

13. Actual Emissions per Pollutant Listed for :
Attach calculations and documentation of emission factors or other estimation methods used.
Emissions Emission
GHG CAS Estimation Control
Pollutants ( ) GHG Pollutants Efficiency Net after
see instructions
(Tons/Year) for year 2022 Method Code all controls)
(See Instructions)
Emissions- Emission Control
Criteria Pollutant Estimation
Criteria Pollutants Efficiency
(NAAQS) Pollutants Code ( ) y Method Code
TOriS/yeaY for year 2022 (Net after all controls)
(See Instructions)
CO CO
NOx NOx
PM(TSP) PM(TSP)
PM10 PM10
PM2.5 PM2.5
SO2 SO2
VOC VOC
Emissions Emission Control
HAP/TAP/Other Pollutants CAS HAP/TAP/Other Estimation
(In alphabetical order) (see instructions) Method Code Efficiency (Net aver
(Pounds/Year) for year 2022 all controls)
(See Instructions)
15

Comments regarding this Operating Scenario (identify by field orgeneral):
If you do not provide all information your inventory will be deemed incomplete and returned to you
To review detailed instructions or other information, go to web page: https://deg.ne.gov/about/divisions/air-quality/air-quality-
data/emissions-inventories/emission-inventories-tools
Most information on this form is not subject to claims as confidential business information.
The emission inventory must be returned (Postmarked) to the appropriate DAQ regional office by May 02, 2023.
If pre-filled information is incorrect,please strike over and replace with correct information.
16

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
Emission Source/Operating Scenario Data
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
1.Emission Source ID (from permit)
or Emission Source Group ID
2. Emission Source Description:
3. Operating Scenario ID/
Description:
4. SCC Description:
5. Throughput/units in 2022: /
(e.g.production or fuel use):
6. Fuel Information %Sulfur %Ash Heat Content
(If fuel is used) /
(Btu/units)
7. Capture Efficiency
(%of Emissions from this Process Vented
to Control Device or Stack):
8. Control Device Information
Order CS-ID Control Devices ID Control Device Description
(as listed in permit)
9. Emission Release Point(ERP) Information: (Sources vented to more than one ERP use additional entry lines):
ERP ID ERP Type Height Diameter Temperature Velocity Volume Flow ERP Description
(in feet) Circle(enter ft (F) (Feet/sec) Rate (Acfm
Rectangle(L x W) )
(in 0.1 feet)
10. Operating Schedule: (Source/Operating Scenario that best characterizes Caleldar Year 2022)
Hours per Day ( ) Days per Week ( ) Weeks per Year ( )
11. Typical Start& End Times For Operating Scenario: Start: End:
12. Seasonal Periods Percent Annual Throughput:
Jan-Feb + Dec % March-May I % June-Aug. I % Sept.-Nov.
17

Emission Source ID:
13. Actual Emissions Per Pollutant Listed for :
Attach calculations and documentation of emission factors or other estimation methods used.
Emissions Emission Control
GHG CAS Estimation
Pollutants (see instructions) GHG Pollutants Efficiency
(Tons/Year) for year 2022 Method Code (Net after all controls)
(See Instructions)
Criteria Emissions- Emission Control
(NAAQS) Pollutant Code Criteria Pollutants Estimation Efficiency
Pollutants (Tons/Year) for year 2022 Method Code (Net after all controls)
(See Instructions)
CO CO
NOx NOx
PM(TSP) PM(TSP)
PM10 PM10
PM2.5 PM2.5
S02 S02
VOC VOC
HAP/TAP/Other Emissions Emission Control
Pollutants CAS HAP/TAP/Other Estimation Efficiency
(see instructions) Method Code y
(In Alphabetical Order) (Pounds/Year) for year 2022 (Net after all controls)
(See Instructions)
18

Emission Source ID:
Comments regarding this Operating Scenario (identify by field orgeneral):
If you do not provide all information your inventory will be deemed incomplete and returned to you
To review detailed instructions or other information, go to web page: https://deg.ne.gov/about/divisions/air-quality/air-quality-
data/emissions-inventories/emission-inventories-tools
Most information on this form is not subject to claims as confidential business information.
The emission inventory must be returned(Postmarked) to the appropriate DAQ regional office by May 02,2023.
If pre-filled information is incorrect,please strike over and replace with correct information.
19

Facility Total CY 2022 Emissions Summary
Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
Record Facility-Wide Totals From all Permitted and Non-Permitted Air Pollutant Emission Sources
GHG Pollutants CAS De Minimus Actual Emissions
(see instructions) Reporting level (Tons/Year)
(Tons) CY 2022 CY2014
Criteria Pollutants De Minimus Actual Emissions
Reporting level (Tons/Year)
(Tons) CY 2022 Reported CY2014
Carbon Monoxide(CO) .5 -
Oxides of Nitrogen(NOx) .5 -
PM/TSP - Particulate Matter .5 PM _ 10 .5 -
PM - 2.5 .5 -
Sulfur Dioxide(S02) .5 -
VOC .5 -
Below and following: Enter,in Alphabetical Order,All HAP/TAP/Other Required by Instructions
(Sum Source Emissions From Emission Source/Operating Scenario Forms)
Hazardous Air Pollutants(HAPs) CAS De Minimus Actual Emissions
and/or Toxic Air Pollutants(TAPs) (see instructions) Reporting level (Pounds/Year)
and/or Other Pollutants (Pounds) CY 2022 CY2014
Acetaldehyde 75-07-0 10
Arsenic&Compounds(total mass of elemental AS,arsine and all ASC(7778394) Ol 0
inorganic compounds)
Benzene 71-43-2 1
Benzo(a)pyrene(Component of 83329/POMTV&56553/7PAH) 50-32-8 1
Beryllium&compounds(Total mass) BEC 1 0
CFC-11 (Trichlorofluoromethane) 75-69-4 100
Cadmium&compounds(total mass includes elemental metal) CDC .1 0
Carbon disulfide 75-15-0 10
Chromic acid(VI)(Component of So1CR6&CRC) 7738-94-5 .01
Formaldehyde 50-00-0 10
20

Hexane,n- 110-54-3 100
MEK(methyl ethyl ketone,2-butanone) 78-93-3 100
Manganese&compounds MNC 10 0
Mercury&Compounds-all total mass includes Hg Vapor HGC .001 0
Methylene chloride 75-09-2 1
Nickel&Compounds,sum total mass includes elemental NIC 1 0
Phenol 108-95-2 100
Styrene 100-42-5 100
Toluene 108-88-3 100
Xylene(mixed isomers) 1330-20-7 100
Pollutants "specified" to add to Pollutant List:
Pollutant Name CAS
Attach supporting documentation and calculations.Report any quantity above the threshold shown on the pollutant list
on the website https:Hdeq.nc.gov/about/divisions/air-quality/air-quality-data/emissions-inventories/emission-inventories-
tools
(If using a blank form,you do not need to replicate the CY 2014 emissions column except to point out errors)
Information on this form cannot be held confidential
Inventory Prepared By
Telephone Number
Fax Number
Email Address
21

The 2022 preparer is a Facility employee or consultant
22

Facility Name: Harrison Construction Division of APAC-Atlantic,Inc. Facility ID : 2000123
235 Marrestop Road Permit : 08976
Murphy,NC 28906 County : Cherokee
DAQ Region : Asheville
North Carolina Department of Environmental Quality
Division of Air Quality
Air Pollutant Point Source Emissions Inventory- Calendar Year 2022
These forms must be completed and returned even if the facility did not operate or emissions were zero
The legally defined "Responsible Official" of record for your facility is Don Mason
This person or one that meets the definition below must sign this certification form.
The official submitting the information must certify that he/she complies with the requirements as specified in Title 15A NCAC
2Q .03040)which define the responsible official as the following:
1. For corporations, by principal executive officer of at least the level of vice-president, or his duly authorized representative,
if such representative is responsible for overall operation of the facility from which the emissions described in the permit
application form originates
2. for partnership or limited partnership,by a general partner
3. for a sole proprietorship,by the proprietor
4. for municipal, state federal, or other public entity, by a principal executive officer, ranking elected official, or other duly
authorized employee
CERTIFICATION STATEMENT:
(Important:Legally Responsible Official,read and sign after all submissions are final.)
I certify that I am the responsible official for this facility, as described above, and hereby certify that the information contained in
this air emissions report, including attached calculations and documentation, is true, accurate and complete. (Subject to legal
penalties of up to $25,000 per occurrence and possible imprisonment as outlined in G.S. § 143-215.3(a)(2))
Responsible Official's Signature Below (use blue ink): Date Signed:
Printed Name: Don Mason
Signature:
This form applies to Non Title V facilities. If this facility is classified as Title V,please telephone your regional office
Emission Inventory Contact at once for proper forms and classification.
Email address of Responsible Official: [e-mail]
Information on this Form cannot be held confidential
23